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Formal and Informal Long-Term Care in the Community: Interlocking or Incoherent Systems?
- TANIA BURCHARDT, EMILY JONES, POLINA OBOLENSKAYA
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- Journal:
- Journal of Social Policy / Volume 47 / Issue 3 / July 2018
- Published online by Cambridge University Press:
- 19 January 2018, pp. 479-503
- Print publication:
- July 2018
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Help with activities of daily living for people in the community is provided through formal services (public and private) and informal (often unpaid) care. This paper investigates how these systems interlock and who is at risk of unmet need. It begins by mapping differences between OECD countries in the balance between formal and informal care, before giving a detailed breakdown for the UK. New analysis of UK Family Resources Survey data for 2012/13 and 2013/14 suggests high levels of unmet need. We investigate who receives formal and informal care, and who receives neither, among the working-age and older populations. We find that while informal care fills some gaps left by the lack of availability of formal services (and vice versa), not all older or working-age disabled people are protected in these ways. Adults living alone and those with high but not the highest levels of difficulty are most likely to have unmet need. Means-tested public entitlements ameliorate but do not remove the increased risk among people in low-income households. The paper concludes that public policy needs to integrate its support for formal and informal modes of care, with particular attention to those groups most at risk of unmet need.
Eight - Health
- Edited by Ruth Lupton, Tania Burchardt, London School of Economics and Political Science, John Hills, London School of Economics and Political Science, Kitty Stewart, London School of Economics and Political Science, Polly Vizard, London School of Economics and Political Science
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- Book:
- Social Policy in a Cold Climate
- Published by:
- Bristol University Press
- Published online:
- 01 September 2022
- Print publication:
- 20 April 2016, pp 147-186
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Summary
The situation on the eve of the crisis
On the eve of the financial crisis, in the summer of 2007, the UK was experiencing a period of substantial and sustained increases in real public expenditure on health. Looking back to 1997, Labour had made the transition into power with health at the top of the political agenda, with Blair urging voters to support Labour in order to ‘save the NHS’. Successive Labour Party manifestos, in 1997, 2001 and 2005, had put emphasis on an overall commitment to the NHS, free at the point of delivery and based on need, not the ability to pay, while highlighting the need to finance a major programme of healthcare investment, modernisation and reform. Real public expenditure on health in the UK had almost doubled during Blair's decade in power, with a real increase from £64.4 billion in 1997/98 to £116.9 billion in 2007/08 (HM Treasury, 2015c).
The results of Labour's large-scale cash investment in healthcare are discussed in detail in our companion paper (see Vizard and Obolenskaya, 2013). The substantial growth in resources during Labour's first two terms in office financed a major supply-side expansion in healthcare, with a considerable expansion of NHS inputs and outputs including staffing, services and healthcare activities. Substantial returns to Labour's investment in health over this period were also reflected in overall indicators of healthcare quality and satisfaction. In 1997, the public had been highly dissatisfied with the NHS, with long waiting lists, pressure for more expenditure on healthcare and demand for private medical insurance going up. By 2007/08, waiting list length and waiting times were down, growth in spending on private medical insurance cover was down, and satisfaction with the NHS had increased substantially.
On healthcare modernisation and reform, a new framework for inspection and regulation had been put into place after 1997 and further evolved during Labour's first two terms. The purchaser– provider split that had been introduced under previous Conservative administrations was retained under Blair, and further reforms emphasised commissioning, organisational decentralisation, competition and patient choice, and information on outcomes. By 2007/08, Labour's healthcare delivery model included autonomous NHS foundation trusts, practice-based GP commissioning and a new system of payment by results, based on the principle that resources should ‘follow’ the patient to the service they choose.
Nine - Adult social care
- Edited by Ruth Lupton, Tania Burchardt, London School of Economics and Political Science, John Hills, London School of Economics and Political Science, Kitty Stewart, London School of Economics and Political Science, Polly Vizard, London School of Economics and Political Science
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- Book:
- Social Policy in a Cold Climate
- Published by:
- Bristol University Press
- Published online:
- 01 September 2022
- Print publication:
- 20 April 2016, pp 187-214
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Summary
The situation on the eve of the crisis
In 2007/08, just before the financial crash unfolded, spending on adult social care in England had reached £20 billion (in 2014/15 prices) after a period of sustained budget increases under Labour in response to the expanding ageing and working-age disabled populations, and in recognition of the historic under-investment in social care. This was providing services to 1.8 million adults, including some of the most vulnerable people in our society: the oldest of the old, younger physically disabled people, people with mental illness or cognitive impairments, and people with drug and/ or alcohol problems.
Complexity in the financing and provision of social care, especially long-term care, was a widely acknowledged problem. Boundaries between the NHS and local authority services, between residential and community care (including domiciliary or home care), between universal and means-tested entitlements and privately paid care, and between formal services and unpaid care provided by family and friends, combined to produce considerable uncertainty among people in need of care and their families about what services they might receive and how much they would be required to pay. Major commissions and inquiries at a rate of one per decade (Griffiths, 1988; Sutherland, 1999; The King's Fund, 2006) had produced recommendations for reform, but none had been fully implemented, as a result of lack of crossparty support or due to concerns about the cost to the public purse. However, in Scotland, the Sutherland Commission's recommendation to fund personal care costs from direct taxation while retaining meanstesting for housing and living costs was adopted in 2002 for people aged 65 or over.
Meanwhile, the trend away from direct provision by local authorities and increasing use of private and not-for-profit providers was continuing (HSCIC, 2014a, Figures 4.5 and 5.1), as was the increase in the number of people receiving payments from local authorities with which to arrange their own care (‘direct payments’). Between 2000/01 and 2008/09, there had been more than a 10-fold increase in the number of working-age people using direct payments, and an even faster increase among the over-65s (from a much lower base), so that by the end of this period there were more than 86,000 recipients of direct payments in England (HSCIC, 2014a, Annex M).
Thirteen - Spatial inequalities
- Edited by Ruth Lupton, Tania Burchardt, London School of Economics and Political Science, John Hills, London School of Economics and Political Science, Kitty Stewart, London School of Economics and Political Science, Polly Vizard, London School of Economics and Political Science
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- Book:
- Social Policy in a Cold Climate
- Published by:
- Bristol University Press
- Published online:
- 01 September 2022
- Print publication:
- 20 April 2016, pp 291-316
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Introduction
Since the economic crisis, increasing political attention has been given to spatial inequalities, perhaps more so than at any time since the late 1990s. Much of the debate and policy effort has focused on economic disparities between regions. In his first major speech as Prime Minister, David Cameron announced a determination to transform England’s heavy reliance on a few industries and a few regions (London and the South East), through breathing new economic life into less well performing areas (Cameron, 2010). A number of new policies and funds ensued, largely focused on the Northern cities, as we describe later in this chapter, and by January 2015, the Minister for Cities, Greg Clark, announced that such was the revival of these cities since the coalition took power that the ‘picture of a north-south divide pulling apart was certainly true in the previous decade … in this decade it is changing. North and south are now pulling in the same direction, which is upwards’ (quoted in Burton, 2015).
Much less is generally known and heard about disparities in social outcomes between regions and their trends than about economic ones. However, in the wake of the Scottish independence referendum of September 2014, political debate around the 2015 General Election revealed a new sense that the interests of ‘the North’ and ‘the South’ were increasingly diverging, to the extent that the politics and policies of London-based government might no longer adequately represent Northern interests. Proponents of a new regional federalism have argued that the issue at stake is not simply the need for a serious focus on the economic revival of areas outside London, but a degree of self-governance to reflect their different conditions, assets, issues and challenges (Mitchell, 2012). The Labour Party leadership campaign, conducted during the summer of 2015, also featured an active debate about how the Party could effectively appeal both to people in the North's working-class industrial communities, and the beneficiaries of the economic success of London and the South East, given their diverging interests and priorities. The Jeremy Corbyn campaign produced its own document on the future of the North (Corbyn, 2015). These arguments focus on the North as a region, not just the economies of its major urban centres.
Twelve - The changing structure of UK inequality since the crisis
- Edited by Ruth Lupton, Tania Burchardt, London School of Economics and Political Science, John Hills, London School of Economics and Political Science, Kitty Stewart, London School of Economics and Political Science, Polly Vizard, London School of Economics and Political Science
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- Book:
- Social Policy in a Cold Climate
- Published by:
- Bristol University Press
- Published online:
- 01 September 2022
- Print publication:
- 20 April 2016, pp 267-290
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Summary
Introduction
Chapter Eleven looked at overall changes in inequality in the six years following the start of the financial and economic crisis in 2007. For the population as a whole, the striking features were the rapid fall in real wages, associated with growing wage inequality, but a large fall in household income inequality (allowing for benefits and direct taxes) between 2009/10 and 2010/11, followed by three years of stability. These overall patterns do not necessarily apply in the same way to all groups within the population. Indeed, the fact that recent stability in overall measures of income inequality resulted from a combination of growing inequalities in the labour market, offset by increases in the relative values of benefits and pensions, already suggests that some groups will have gained and others will have lost.
This chapter draws on detailed analysis of how the changes in the labour market, incomes and wealth affected particular population groups, and of how inequalities changed within those groups (Hills et al, 2015a). We present here some of the patterns this revealed when dividing the population by gender, age, ethnicity, housing tenure, region and disability status. The figures are for regions across the whole of the UK, with the exception of wealth, which is for Great Britain (excluding Northern Ireland). The analysis uses the baseline of the results originally presented by the National Equality Panel (Hills et al, 2010) which was able to use data from the years around 2007. As in Chapter Eleven, we show the position up to 2013 for labour market outcomes and up to 2010-12 (the two years to June 2012) for wealth. For household incomes (both before and after housing costs) we were able to look at the position up to the financial year 2012/13, a year before the latest year available for the national statistics used in Chapter Eleven. There was little change in overall income inequality between the two years, but that stability may mask further changes between and within groups beyond those we can show here. Note that these statistics do not reflect the effects of the ‘welfare’ and other reforms taking place from or after 2013 discussed in Chapter Two earlier.
Ten - Public and private welfare
- Edited by Ruth Lupton, Tania Burchardt, London School of Economics and Political Science, John Hills, London School of Economics and Political Science, Kitty Stewart, London School of Economics and Political Science, Polly Vizard, London School of Economics and Political Science
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- Book:
- Social Policy in a Cold Climate
- Published by:
- Bristol University Press
- Published online:
- 01 September 2022
- Print publication:
- 20 April 2016, pp 217-244
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Welfare provision, finance and choice
The changing role of the state in relation to what may be broadly considered ‘welfare’ is a theme that threads through all of the policy areas considered in this book. In some domains, such as early childhood, involvement of the state has increased significantly over the past two decades, while in others, such as housing, it has shrunk. Moreover, change has taken place along several dimensions – not just in terms of expenditure, but also in relation to forms of provision, the degree of regulatory control and user choice. This complexity means that a straightforward diagnosis of ‘privatisation’ is not helpful or perhaps even meaningful. As Powell and Miller (2013, p 1058) note: ‘The term privatization is multidimensional, and definitions and operationalisations of the term are often implicit, unclear, and conflicting.’ Instead, what we offer in this chapter is an account of some of the changes in policy in relation to the role of the state and their consequences for the distribution of spending – public and private – on welfare activities in the period from the eve of the financial crash to the present day.
To provide a structure for this task, we build on a framework developed by Burchardt, Hills and Propper (1999) and subsequently applied by Smithies (2005), Edmiston (2011) and Hills (2011). The framework comprises three dimensions – provision, finance and decision – each of which may be public or private, and which may occur in any combination (see Figure 10.1). The ‘pure public’ segment is what we might consider to be the archetypal post-war British welfare state – tax-financed, provided by a publicly owned and run organisation, and with little or no choice on the part of the beneficiary about how much or from whom to receive the service. Emergency treatment in an NHS hospital is an example. At the opposite corner, the ‘pure private’ sector is activity undertaken by individuals at their own initiative and purchased in the free market, such as private medical insurance.
Four - Schools
- Edited by Ruth Lupton, Tania Burchardt, London School of Economics and Political Science, John Hills, London School of Economics and Political Science, Kitty Stewart, London School of Economics and Political Science, Polly Vizard, London School of Economics and Political Science
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- Book:
- Social Policy in a Cold Climate
- Published by:
- Bristol University Press
- Published online:
- 01 September 2022
- Print publication:
- 20 April 2016, pp 59-80
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The situation on the eve of the crisis
Throughout this book, 2007 is referred to as the last year of the ‘warm climate’ for social policy that Labour enjoyed. In schools policy, it also represents a turning point, with Ed Balls taking over as Secretary of State for Education and beginning to take policy in new directions.
The Labour programme for schools up to 2007 had four key themes. The main policy emphasis was on pushing up standards of teaching and learning. National Strategies were introduced to provide teachers with standardised materials and guidance, supported by advisers. The government set ‘floor targets’ for minimum performance, naming and shaming schools that did not reach them, and forcing some to close and reopen with new leadership. Teachers’ salaries were increased, and performance pay introduced. Teacher training was reformed and a new workforce agreement was signed, designed to cut down the time teachers spent on administration, resulting in a large increase in the number of support staff.
Curriculum and assessment was a second theme, but a much less prominent one initially. Indeed, a key decision was made not to accept the recommendations of the 2004 Tomlinson report, which proposed new 14-19 diplomas in place of GCSEs, A-levels and vocational qualifications. However, a wider range of vocational courses, deemed equivalent to GCSEs, was introduced. A third theme was structural reform – again something less strongly emphasised initially, when David Blunkett pledged that his priority would be standards, not structures. In practice, Conservative policies of choice and diversity were extended. Schools were encouraged to develop specialisms, and from 2002 academy schools were introduced to replace struggling schools in disadvantaged areas. The way was paved for subsequent coalition reforms through decisions to give parents the right to request new schools, move local authorities into commissioning roles, and encourage schools to join together in federations.
Fourth, there was a prominent focus on addressing socioeconomic inequalities, partly through the academies programme, but also through the ‘Teach First’ programme (which brought top graduates into teaching in the most disadvantaged schools), an increasingly redistributive school funding formula, and targeted area-based schemes such as Excellence in Cities and the London Challenge. Labour’s Building Schools for the Future (BSF) programme, designed to renew the entire secondary school building stock in 15-20 years, was also initially targeted on the most disadvantaged areas.
Three - Young children
- Edited by Ruth Lupton, Tania Burchardt, London School of Economics and Political Science, John Hills, London School of Economics and Political Science, Kitty Stewart, London School of Economics and Political Science, Polly Vizard, London School of Economics and Political Science
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- Book:
- Social Policy in a Cold Climate
- Published by:
- Bristol University Press
- Published online:
- 01 September 2022
- Print publication:
- 20 April 2016, pp 35-58
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Summary
The situation on the eve of the crisis
Until 1997, early childhood sat on the periphery of government concern in the UK. With the exception of health check-ups and universal Child Benefit, the state largely stepped out of a baby’s life after birth, and only stepped back in when the child arrived at primary school more than four years later. While some inner-city local authorities provided free nursery education, for the most part nurseries, playgroups and toddler groups were organised by the voluntary or independent sector. Maternity leave provision was among the least generous in Europe, and state spending on childcare almost non-existent.
By 2007 the landscape for young families looked very different. Investment in early childhood had been a key feature of the Labour administration for a decade, promoted by a constellation of Labour politicians because it promised to further a number of policy goals at once. Centre stage was the goal of eradicating child poverty in 20 years, which required both higher family incomes in the immediate term and a focus on early child development, with an eye on giving the next generation of parents a fighting chance of non-poverty wages. Policies that made it easier and more financially viable for mothers (and fathers) to combine work and family responsibilities were also recognised to be key to furthering growth, promoting gender equality and reducing gender pay gaps.
Between 1997 and 2007 spending on cash benefits for families with children in the UK nearly doubled. Most of the increase came from the expansion of targeted in-work benefits under the tax credit system, but benefits to out-of-work families with children were also made more generous. Poverty fell steeply for some household types, and especially for children living with a lone parent working part time (Stewart, 2009). Poverty also fell much more quickly in families with a child under five than for those with older children, reflecting a series of changes to benefits favouring these households: Income Support allowances for children under 11 were increased in line with those for older children, and there were new benefits for babies, including the near-universal baby tax credit and the £500 Sure Start Maternity Grant for low-income families (Stewart, 2013).